Transcript About the Midterm

About the Midterm
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OBgyn Week 7
Normal Pregnancy
Conception
• Traditionally, involves a fertile woman and a
fertile man.
(These days can involve egg donors, sperm donors,
surrogates, fertility hormones, artificial implantation, and
other techniques which will not be covered in this lecture)
• Possible during fertile window of woman’s
cycle (around ovulation)
• Sperm must travel through cervix, uterus,
fallopian tubes to reach and fertilize egg
Conception
• Sperm undergo enzymatic reactions
(while traveling through cervical mucus
and fallopian tubes) to help penetrate
the protective layers around the ovum
• Sperm chemically attracted to ovum
– Progesterone
– Follicular fluid from ovum
Conception
Conception
• Fertilization occurs in Fallopian tube,
zygote (fertilized egg) continues to divide
as it travels to uterus and implants
• Takes 3-4 days for embryo to reach uterus
• Implantation generally occurs ~3-4 days
after embryo enters the uterus
Fertilization to Implantation
Fertile Days of Cycle
Factors to consider:
• Ovulation occurs ~day 14 (anytime of day)
• Ovum can survive up to 24 hours after ovulation
• Sperm can survive in the vagina up to 48 hours
after ejaculation
• So fertile window is ~days 11-16 of cycle
(if trying to conceive, these are best days;
expand to ~days 8-19 if trying NOT to conceive)
– strict day correlation depends on cycle regularity
– remember - follicular phase can vary in length
Fertility Symptoms
• Charting of menses
– Helps determine fertile days, esp if regular cycles
• Cervical mucus
– Will be thicker, stretchy when most fertile
• Cervical position and feel
– Cervix softens, moves further from introitus when fertile
• Basal body temp
– Increases just after ovulation
• Hormone levels
– LH surges prior to ovulation (must draw blood to test)
• Salivary crystallization
– At-home test kits available
Cycle charts
Multiples
• Most commonly twins or triplets
• May arise from:
– Release and fertilization of multiple ova
(fraternal twins)
– Division of zygote into two embryos
(identical twins)
Division during stage when cells are totipotent
– Combination of these
– Identical triplets or quadruplets also possible
• High risk of pre-term delivery, low birth weight
Early Pregnancy Sx
All of these are due to hormone level changes:
• Nausea / vomiting (esp in AM)
• Commonly lasts until ~week 12-15, when placenta takes
over roll of hormone production from corpus luteum
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Swollen / tender breasts
Mood changes / irritability
Fatigue
Leucorrhea: white, thicker vaginal discharge
Lack of menstrual period
• Will have been pregnant ~2 weeks by this point
• May have light spotting lasting ~1 day (more may be sign
of spontaneous abortion or of ectopic pregnancy)
Abnormal Sx
Symptoms of ectopic pregnancy or
spontaneous abortion may include:
Cramps
Severe abdominal pain
Bleeding
Spotting > 1 days
Fainting or Dizziness
Pregnancy Diagnosis
• Urine b-HCG - accurate at time of missed period
(home test kits available OTC)
• Serum b-HCG - quantitative tests most sensitive
• Ultrasound (abdominal)
– 5-6 weeks can see gestational sac
– 8 weeks can see heart beat to assess viability
Vaginal Ultrasound can determine heart beat,
gestational sac at 5 weeks
Later Signs of Pregnancy
– Softening and bluing of cervix
– Enlargement of uterus (may be palpated by 15 wks)
– Fetal heart tones (Doppler or fetascope)
• 120-160bpm, so easy to tell apart from mother’s
• May be detected as early as 10 wks
• Lack of FHT by 12-14 weeks is concerning, may be due to:
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Wrong date determination
Non-viable fetus
Posterior position of fetus
Thick abdominal wall
Retroflexed uterus
Later Signs of Pregnancy
• Quickening: first fetal mvmt felt by the mother
– Primiparous: 18-20 weeks
– Multiparous: 16-19 weeks
• Braxton Hicks contractions: localized uterine
contractions that may start at 20 weeks; very
irregular and variable
• At 20 weeks, ballotment: moveable baby
Length of Pregnancy
• Estimated Due Date = 40 weeks (280 days)
after first day of last menstrual period
• Naegle’s rule:
subtract 3 months from LMP, add 7 days, add 1 year
• Add 266 days from exact day of conception
• 85% of women deliver around EDD; 10% early, 5% late
• “Normal” can vary from 37-42 weeks
• LMP used to estimate gestational age
• And remember, fertilization usually occurs
~2 weeks after first day of LMP
• Conception age refers to date of probable conception
• ~2 weeks less than gestational age
Establishing EDD
• Difficulties with establishment of Due Date
– Irregular or abnormal menses
• Miscarriage
• Lactation (annovulatory for 6-12 months)
• Gynecological problems (e.g. polycystic ovaries)
– Other interfering factors
• Low dose OCPs
• Early or late ovulation
• Poor recording of menstrual history
Establishing EDD
• Importance of establishing correct EDD
– Determine pre or post maturity
• Important if home birth (safe to deliver weeks 37-42; if
premature or postdate, need to refer to hospital)
– Determine IUGR (Intrauterine growth retardation)
– Determine multiple pregnancy or abnormal levels
of amniotic fluid
– Determine paternity
– Gestational age important in considering TAB,
amniocentesis, alpha fetal protein
Maternal Changes
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Weight gain
Loosening of joints
Hormonal changes
Increase in blood volume
Enlargement of uterus, crowding of
abdominal and pelvic organs
• Enlargement of breasts
Weight Gain
• Normal weight gain
~30 lbs if healthy weight at start of pregnancy
~9 of these lbs are weight of fetus, placenta, amniotic fluid,
uterine hypertrophy, increased blood volume, breast
enlargement, maternal intra/extracellular volume
• Variables to weight gain:
– Age, parity, income, maternal education, etc.
– Large weight gain associated with LGA (large for
gestational age) babies
• Contributes to maternal obesity, gestational diabetes,
increased risk for CV dz and diabetes later in life
– Low weight gain associated with SGA babies
• Greater risk for preterm labor
Maternal Weight Gain
• National Academy of Science
recommendations according to BMI
– 28-40# for underweight women
• 5# in first trimester; >1# week thereafter
– 15-35# for women at normal weight
• 2-4# in first trimester; 1# week thereafter
– 15-25# for overweight women
• 2# in first trimester; <1# week thereafter
Maternal Changes
Physiologic Changes
– Cervical changes: effacement and dilation
• Thick clot of mucus in cervical os: mucous plug
• Cervix softens and becomes cyanotic (increased
vascularity)
• Change in consistency in cervical mucus
– Uterine changes:
• Displaces intestines laterally and superiorly
• Increases tension on on broad and round ligaments
• Uterus also undergoes irregular contractions
– Unpredictable, nonrhythmic, aka Braxton-Hicks
– Vaginal changes:
• Softening of tissues
• Increased cervical mucus
• Decreased pH (3.5 to 6) (antibacterial function?)
Phys Changes
– Ovaries
• Ovarian function ceases, maturation of new follicles
suspended
• Corpus luteum produces progesterone (until ~week 12,
when placenta takes over this function)
• Corpus luteum also secretes relaxin hormone
– Changes in breasts:
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Increased tenderness in first weeks
Increase in size
Nipples become enlarged and more deeply pigmented
Colostrum secreted pre or post-natally
Phys Changes
– Musculoskeletal changes
• Softening of ligaments (esp. sacro-illiac and pubic
symphisis) due to relaxin hormone
• Lumbar lordosis
• Loosening of all joints
– Often noticed as increase of foot length / shoe size
– Skin changes:
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chloasma (“mask” of pregnancy)
linea nigra on abdomen
striae
increased hair growth, increased perspiration
Phys Changes - CV
– Cardiovascular changes
• Increased cardiac outflow by 30-40%
• Increase in blood volume by >35%
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Increase in body mass (enlarged uterus)
Facilitates blood flow/ gas exchange to placenta
Protects mother against excessive blood loss during labor
Greater increase in plasma than erythrocytes
• Benign ejection systolic heart murmurs
• Increased pulse rate 10-15bpm
(How would you expect her pulse to feel?)
– Edema of pregnancy
• Increased capillary pressure and permeability
• Fetal pressure in pelvis decreases venous return of lower half
of body
More Physiologic Changes
– Increase in cellular respiration for fetus/placenta
and mom
– Shortness of breath dt restriction on diaphragm
– Kidneys about 1 cm larger during pregnancy
– Increase in dental caries
– Decreased secretion of HCL and pepsin
– Decreased gastric emptying and intestinal motility
– Increased metabolic rate by 20%
Endocrine Changes
– Increased thyroid function (free, active
thyroid hormone T3 remains the same)
– Incrased prolactin, cortisol, aldosterone
– Decreased GH, FSH, LH
– Difficulty balancing blood glucose
• Glucose as energy source favored by fetus
– Estrogen increases 1000x (ovaries and
adrenals)
– Progesterone increases 10x
Estrogen Effects
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Influences growth and fxn of uterus, breasts, labia
Increases pliability of CT, joint relaxation
Increases adipose tissue (fat stores)
Increases skin pigmentation
Increases Na+ and volume retention
Stimulates 3rd trimester prostaglandin production
Associated with mood swings
Increases insulin production/ secretion as well as
tissue sensitivity to insulin
– Increases uterine receptivity to progesterone and
oxytocin
Progesterone Effects
– Produced by corpus luteum, then by
placenta
– Increases the blood supply of endometrium
– Suppresses maternal immunological
response to fetus
– Inhibits contraction of uterus
– Relaxes smooth muscle (bladder tone,
slows GI motility)
– Radically decreases at labor onset
More Endocrine Changes
– Prolactin
• Produced by maternal and fetal pituitary glands, uterus
• Sustains milk production and regulates milk composition
– Prostaglandins
• Produced by mother, fetus, placenta
• Soften cervix, prime maternal body for labor
– Oxytocin
• Produced by hypothalamus, released by pituitary
• Stimulates uterine contractions, milk let down/ ejection
• Distension of cervix and vagina stimulates release of
oxytocin and prostaglandins during labor
Endocrine Changes - HCG
– bHCG (beta human chorionic gonadotrophin)
• Secreted by fetus starting day 6-8
• Prevents degeneration of corpus luteum so that E and P
continue to be secreted
• Maximum levels at 7-16 weeks
• At 8-12 weeks, promotes testosterone synthesis and
secretion for male sexual differentiation
• Used in diagnosis for quantitative pregnancy tests/
ectopic pregnancy
Endocrine Changes - HPL
– HPL (human placental lactogen)
• aka HCS (Human Chorionic Somatomammotropin)
• Produced by placenta
• Decreases maternal insulin sensitivity
– Elevates maternal blood glucose levels with decreased
maternal glucose usage = more available for fetus
• Elevated during hypogycemia to mobilize free fatty acids
for energy for maternal metabolism
• Increases lipolysis
– Glucose preferentially used as fuel by fetus, maternal
energy increasingly comes from fat stores
• Decreases hunger sensation and diverts maternal CHO
metabolism to fat metabolism in 3rd trimester
• Plateaus in 3rd trimester
Trimesters
• Pregnancy divided into trimesters, each
~3 months (13-14 weeks)
– 1st : weeks 0-13
– 2nd : weeks 14-28
– 3rd : weeks 29-40
Week-by-Week
Developments
• First Trimester (embryonic development)
*Highly sensitive to teratogens during this stage*
– Weeks 1 and 2: remember, this is preconception:
mother’s body prepares for ovulation, fertilization
– Wk 3: fertilization occurs, cell division begins
– Wk 4: CNS begins to develop, angiogenesis,
primitive cardiovascular system
– Wk 5: neurogenesis, brain activity, heart beat
HCG levels detectable via home test kits
– Wk 6: embryo size of a bean, face developing
– Wk 7-8: Eyes, hair, all essential organs, movement
– Wk 8: Embryonic stage over, fetal stage begins
First trimester continued
– Wk 9-12: dvpmt of fetal muscle, cartilage, genitals,
Fetal Heart Tones detectable
– Wk 13: fetus is about the size of a peach
– Common maternal symptoms:
• Morning sickness, breast tenderness/swelling, fatigue,
weight gain, constipation, heartburn, food cravings,
frequent urination
– Recommendations:
• Focus on good nutrition: nutrient-dense and fiber-rich
foods, avoid refined carbs, eat small, frequent meals
• Ginger, acupuncture to relieve nausea
• Gentle exercise to aid circulation, bowel mvmts, fatigue
• Kegel exercises now to help prevent incontinence later
Fetal development
2nd trimester (wk 14-28)
Further organ development and function
Fetus swallows fluid, urinates, sleeps and wakes
– Week 16: toes, fingers, eyelashes
– Wk 17: fetus can hear outside noises; mom may start
to be visibly pregnant, may feel “quickening”
– Wk 20: gender identification possible with ultrasound
– Wk 21: mom SOB, fetus presses against diaphragm
– Wk 24: Check baby’s position; if born at this time, there
is a chance of survival of infant
Lack of lung dvpmt, low body weight are greatest risk factors
– Wk 25: all organs formed, now mainly growth; risk for
pre-eclampsia begins
2nd trimester
• Common maternal symptoms:
– Striae, linea nigra, hemorrhoids and other
varicosities, increased allergen sensitivity,
swollen feet/ankles, shortness of breath
– Increased incidence of dental caries (cavities)
• Recommendations:
– Continue to focus on good nutrition
– Rest, nap, put feet up periodically
– Good oral hygiene especially important
Fetal development
3rd trimester (wk 29-40+)
Fetal weight gain ~1 ounce/day
Brain develops rapidly: Maternal nutrition - omega 3s
– Wk 33: fetus moves downward, head down
– Wk 34: testes descend (in male fetus)
– Wk 37: lung surfactant produced
– Wk 38-40: ready for delivery!
– Wk 41-42: still within normal, low-risk range
U.S. averages for infants at term birth:
Female wt: 7 lbs, male wt: 7.5 lbs, length: 20”
Placenta
• New organ (!) develops for pregnancy only
• Develops from embryonic cells (outer layer of
blastocyst)
• Allows gas exchange (oxygen, CO2) without
mixing of maternal and fetal circulation
• Also permeable to vitamins, glucose, free
fatty acids and electrolytes, and antibodies
Placental Circulation
• Mother’s circulation
connects through
uterine wall
• Fetal circ from placenta
via umbilical cord
• Placental circulation
reverse of convention
– Arteries carry
deoxygenated blood
– Veins carry oxygenated
blood
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Placenta in Multiples
• Depends on:
– Dizygotic twins v. monozygotic twins
– Time at which cleavage of monozygote occurred
• A= dizygotic twins (two sperm fertilized two eggs)
• B= monozygotic twins, cleavage of zygote 4-8d post fertilization
• C= monozygotic twins, cleavage of zygote 8-12d post fert.
Nutrition - general
• Early fetal development
– Folate: needed for proper brain and CNS development must have good levels at very start of pregnancy to prevent
defects
– B12: also needed for proper fetal CNS dvpmt
– Vitamin A: overdoses can cause defects, so important not to
megadose during pregnancy
– Prenatal vitamins
• Maintenance of pregnancy
– Extra calories (~100-300 more/day)
– Quality fats (including omega 3s), oils, and protein
– Nutrient-dense, fiber-rich foods
– Avoid refined carbs and “empty” calories!
Nutrition
• Do not restrict salt during pregnancy!
• Electrolytes needed to balance increased blood volume
• Low sodium diet can lead to elevated BP (drop in blood
volume makes kidneys react as if hemorrhage occurred
and release renin, which constricts blood vessels)
• No weight-loss diets during pregnancy!
• If pt overweight, focus on healthy food choices
• Protein needs increase (60-100g/day)
• Increased risk for Pregnancy-induced hypertension with
malnutrition, low protein, low calories and low salt
• Can monitor protein status by checking serum albumin
• Iron
Nutrition - minerals
• 30mg/day (60-90mg/d if mom anemic)
• Better taken with vitamin C, away from tannins
• Calcium
• 600-1200mg/ day supplemental to dietary intake
• Increased PTH stimulates calcium release from bones
• No net bone loss during pregnancy, but bone loss can
occur during lactation with inadequate calcium intake
• Deficiency: muscle spasm, bleeding gums, headache
• Zinc
• 15-30mg/day; >30mg may be teratogenic
• Important for protein synthesis
• Deficiency associated with: infertility, chronic SAB, PIH,
dysfunctional labor, infections
Nutrition - folate
• Folic acid
* Start taking before pregnancy*
• 800-1000mcg/day
• Needed for DNA synthesis, protein metabolism,
neurological development
• Deficiency assoc with neural tube defects (spina bifida)
• Deficiency common in vegan diets, smoking, OCP use
• Should always supplement with Vitamin B12, as it can
mask symptoms of B12 deficiency
Nutrition - vitamins
• B vitamins
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25% women in US are deficient in B vitamins
50mg/day B6
Helps with nausea/ vomiting
B12 deficiency results in CNS defects in baby
Esp. important for vegans to supplement B12
• Vitamin C
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500-1000mg/d
Megadoses (10g) may cause miscarriage in early weeks
May also interfere with pregnancy test results
Decreased incidence of SIDS if taken during pregnancy
and continued while breast feeding
Nutrition - vitamins
• Vitamin A
• Use beta-carotene in pregnancy as high doses of vit A
may be teratogenic (>10,000IU)
• Be aware of patients using vitamin A as skin treatment
(acne, wrinkles)
• Vitamin D
• Recent research: deficiencies increase risk for C-section
• Sunshine is best source
• Supplement doses determined by serum vitamin D levels
Nutrition - prenatal vitamins
• Take before and throughout pregnancy
• Most necessary vitamins and minerals
are included in prenatal formulas
• May need extra iron if anemic
• Need omega 3 fatty acids (not included)
• And, of course, still need a good diet
Nutrition - multiples
Nutrition for multiple gestation (twins, etc.)
• Each fetus requires additional increase
in mother’s total blood volume
• Each fetus requires ~30g protein and
200 calories daily
• Higher dose prenatal vitamins
• Frequent meals
Maternal Malnutrition
• Malnutrition increases risk of:
– Prolonged, difficult labors
– Pre-eclampsia and eclampsia (part of PIH)
• Stroke, seizures, death
– Placental abruption
– Low birth weight infants
Exercise During Pregnancy
• Healthy, fit women can often continue their
regular exercise programs
• Ensure good hydration
• May fatigue much faster
• Don’t increase intensity beyond pre-pregnancy levels
• Yoga and walking are recommended for
women who are not used to exercising
• Bicycle riding is not recommended, as center
of gravity changes - increase risk of falls
Exercise - contraindications
Pre-eclampsia
Severe heart disease
Multiple gestation
Preterm labor (now or prior
pregnancy)
Incompetent cervix
Premature rupture of
membranes
Placenta previa after 26w Lung disease
Persistent 2nd or 3rd
trimester bleeding
Intrauterine growth
retardation
Discontinue Exercise if:
Amniotic fluid
leakage
Calf pain/ swelling
Dyspnea before
exertion
Headache
Chest pain
Muscle weakness
Decreased fetal
movement
Dizziness
Preterm labor
Vaginal bleeding
Conventional Prenatal Care
• First visit usually ~week 6-10
– Medical history and full physical exam
– Ultrasound
– Labwork: CBC, UA, vaginal culture, STI tests,
blood type, Rh factor, metabolic panel
• Routine care - monthly visits until wk 28
– Lab results, vital signs, fetal heart rate
– Later: fundal height measurement
• Visits every 2 weeks until week 36
– Stay current with any changes in vital signs
– Check for group B strep with vaginal culture
• Weekly visits until delivery
Ultrasound
• Often done at:
• 10 wks: determine if fetus is living and due date
• 20 wks: check anatomy and for structural defects
• Week 32-34: assess fetal size, position and wellbeing
High Risk Pregnancy
• Defined as any of the following:
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Maternal age <15 or >35
Maternal weight <100lbs pre-preg or obese
Maternal height <5’
History of complications with previous pregnancies
(including stillbirth, fetal loss, preterm labor and/or
delivery, small-for-gestational age baby, large
baby, pre-eclampsia or eclampsia)
– More than 5 previous pregnancies, even if normal
– Bleeding during the third trimester
– Abnormalities of the reproductive tract, including
uterine fibroids
High Risk Pregnancy
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• Defined as any of the following:
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Rh incompatibility
Pre or post-term delivery (<37 or >42 wks)
Multiples
Hypertension
Gestational diabetes
Infection of vagina, cervix, or kidneys
Fever
Acute surgical emergency (appendicitis, etc.)
Chronic illness (sickle cell anemia, AIDS, etc.)
• High-Risk status necessitates delivery care
from highly trained specialists
Rh Incompatibility
• In women with Rh neg blood types
• Occurs only if baby in womb has Rh positive
blood type (father must have Rh pos blood for
this to be genetically possible)
• Danger lies in exposure to second Rh pos
fetus - mother’s immune system may develop
antibodies to fetal blood with first exposure
and attack blood of second fetus
• Treatment is Rh immune globulin injection
(Rhogam shot) in 7th month of gestation and
within 72 hours of delivery
Avoid During Pregnancy
Teratogens - some medications, alcohol, solvents, chemicals
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Alcohol
Androgens and testosterone
ACE inhibitors
Coumarin
Carbamazepine
Anti-folates (methotrexate)
Cocaine
DES (no longer available in U.S.)
Avoid During Pregnancy
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Lead, Lithium, Mercury
Phenytoin
Streptomycin, kanamycin
Tetracyline
Thalidomide
Trimethadione, paramethadione
Valproic acid
Vitamin A in high doses
Teratogen Classification
• Weigh risk vs benefit case-by-case
– CATEGORY A:
• Controlled studies in humans have demonstrated no fetal
risks. There are few category A drugs. Examples include
prenatal vitamins, but not massive dosages of vitamins.
– CATEGORY B:
• Animal studies indicate no fetal risks, but there are no
human studies; or adverse effects have been
demonstrated in animals, but not in well-controlled
human studies.
Teratogen Classification
continued
– CATEGORY C:
• There are either no adequate studies, either animal or
human, or there are adverse fetal effects in animal
studies but no available human data. Many medications
pregnant women use fall into this category.
– CATEGORY D:
• There is evidence of fetal risk, but benefits are thought to
outweigh the risks.
– CATEGORY X:
• Proven fetal risks clearly outweigh any benefit.
– Accutane
Common Complaints
During Pregnancy
(The following slides list common symptoms
experienced during pregnancy, along with
conditions that must be ruled out, and
recommendations for treatment and prevention)
Common Complaints
During Pregnancy
• Fatigue: need to rule out anemia
– TCM ddx?
• Drowsiness
– Due to increase in progesterone, worst in 1st
trimester
– Be careful driving!
– Take naps (also helps nausea)
– Remind her it is not forever
– Make sure diet and iron levels ok, if so, don’t fight
urge to rest
Common Complaints
• Mask of pregnancy: chloasma
– Temporary increased pigmentation due to hormone changes
– Most common in women with poor diet, liver not processing
hormones well
– More common in multips
Common Complaints
• Rashes
– Increased metabolism, sweating, flesh leads to
increased skin/skin contact
– Increased sensitivity to allergens
• Pruritis
– Hormones or increased vascularization
– Can be early sign of PIH (dt decreased Kd
function)
– Skin stretching
– Oatmeal bath, adequate dietary oils and fats
Common Complaints
• Blood sugar imbalance
– Aggravated by fetal competition for blood glucose,
hormone fluctuation
– Frequent small meals, increase protein (60-90g/d)
– Avoid sugar (max 1 glass of juice or one fruit/ day)
• Insomnia
– Can’t get comfortable
– Increased frequency of urination
– Worry/ anxiety
– Usually worse in 1st and 3rd trimesters
– Counseling, warm baths, pillows behind back, between
knees, under belly, wet sock treatment, exercise,
decrease caffeine
Common Complaints Nausea
• Nausea/ vomiting
– b-Hcg decreases stomach acid and appetite;
blood sugar imbalance also contributes
– Usually n/v decrease after 12-16 weeks
– Nausea is a good sign: lower likelihood of SAB
• No nausea mb sx not enough b-hcg being produced
– Hyperemesis graviderum: severe n/v, need to be
hospitalized for dehydration
Common Complaints Nausea
• Suggestions:
– eat small, frequent meals (every 3-4h), especially
protein, even if not hungry
– Protein snack before bed or during the night
– Increase complex carbohydrates; have dry
crackers at bedside, eat first thing in the morning
– Consider eliminating food intolerances
– Precede meals with 1Tbsp. Apple cider vinegar
– Visualizations, acceptance of pregnancy,
grounding, roots pulling down to earth
Common Complaints
• Heartburn
– Reflex from pressure on stomach; usually late in
pregnancy but may be early on
– Avoid lying down for 2h after eating; eat small,
frequent meals slowly
– Avoid fats, spicy foods, carbonated drinks
– Chew gum to increase saliva, digestive enzymes
– Warm teas but avoid mint (relaxes sphincter)
• Pytalism (excess salivation)
– Hormones of pregnancy, CHO deficiency
• Eat CHO at every meal
Common Complaints
• Pica
– Desire for non-foods such as dirt, paint chips
– Generally a sign of protein or calcium deficiency–
need to improve diet
• Constipation
– Progesterone relaxes smooth muscle, decreases
gut motility; later in pregnancy uterine size crowds
bowels
– Avoid straining (hemorrhoids)
– Increase fluids, fiber, prune juice (better if heated),
exercise, decrease stress
Common Complaints
• Diarrhea
– Common; may alternate with constipation
– Increase fiber
• Flatulence
– Due to decrease in gut motility, pressure on
bowels
– Chew food well, avoid offending foods,
carbonation
– Digestive enzymes, probiotics
Common Complaints
• Nosebleeds/ bleeding gums
– Increased vascularity, calcium deficiency
– Ensure bleeding stops within normal time; if any
doubts, check platelets, pro-thrombin time
• Abdominal Pain
– Need to rule out: placental abruption, uterine
infection, ectopic PG, Kd infection, premature
labor, ruptured ovarian cyst
– Round ligament pains, braxton-hicks contractions,
baby kicking
• Shortness of breath
– Anemia, mechanical pressure
Common Complaints
• Heart palpitations
– Increased blood volume and pressure increases
work load on heart
– Aggravated by increased weight, pressure of uterus
on diaphragm
– Anemia
– Rule out thyroid (esp. hyperthyroid)
– Consider referral to cardiologist
• Breast tenderness
– Well-fitting bra, avoid underwire (blocks milk ducts)
– Proper vitamin E intake
Common Complaints
• Hemorrhoids
– Increased laxity of veins, increased pressure on
pelvic venous system and lymphatics
– Constipation causing straining, increasing pressure
• Varicose veins
– Same etiology as hemorrhoids; often a genetic
component, more common in multiparous women
– Common locations along leg, behind knee
– Need to monitor for thrombophlebitis
– Keep legs elevated above heart 15min of every 4h
– Decrease length of time spent standing
Common Complaints
• Edema
– Increased uterine size leads to slow venous return
– Increased permeability and blood volume pushes
fluid out into interstitial space
– Need to rule out PIH, esp. with facial edema
• Swelling in ankles at end of day, esp. after standing; may
want to remove rings on fingers (normal)
– Rest at least 15min/4hours
– Check nutrition: proper protein, salt, water intake
Common Complaints
• Low back pain
– Relaxin softens SI joints, pulls on lumbar
musculature, puts pressure on nerves; causes
joints to be hyper-mobile
– Change in body weight and its distribution
changes posture
– Larger uterus increases lumbar lordosis
– Wear sensible shoes, avoid heavy lifting (>25#)
– Prenatal exercises: pelvic rocks, knee to chest on
waking, walking, swimming, check posture
– Don’t start new sports during pregnancy
Common Complaints
• Leg cramps
– Relative buildup of lactic acid, Relative calcium
deficiency, Decreased circulation in legs
– Stretch legs, massage during cramping
– Calcium, magnesium
• Headache
– In addition to all non-PG related etiologies,
increase in b-hcg, blood volume changes, anemia,
hypogycemia, calcium deficiency, PIH
– Avoid aspirin, ibuprofen (decrease platelets)
– Hot foot back with cold compress on neck
Common Complaints
• Syncope/dizziness
– Increase vagal response to position change,
increased demand on heart, anemia, increased
blood volume, hypoglycemia
– Get up slowly, careful with hot baths, treat cause
• Stretch marks
– Approx. half genetic, other half due to excess
weight, poor tissue support
– 50% women get them; of these 50% go away
postpartum
– Exercise to improve muscle tone
– Vitamin E, shea butter
Common Complaints
• Hydrorrhea gravidarium:
• Normal, profuse watery discharge, white or clear, no itch
• Can be confused with water breaking (but won’t be
alkaline like amniotic fluid)
• Yeast infection
• Increase in estrogen, change in pH
• Cotton underwear, good hygiene, low sugar
• Trichomonas vaginal infection
• Should not be treated until postpartum
• Flagyl contraindicated during pregnancy
• Bacterial vaginosis
• Cleocin antibiotic cream vaginally ok during PG
Key Concepts
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Fertile window is days 11-16 of cycle
Gestational age begins at LMP
Normal pregnancy length is 40 weeks
Proper folate levels nec before conception
Focus on good nutrition, not weight gain
What is Rh incompatibility? Who is at risk?
• There are MANY changes during pregnancy
Know which are normal, which need investigation